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PubMed2001

A systematic review of predictors of maintenance of normotension after withdrawal of antihypertensive drugs.

BACKGROUND: The identification and treatment of hypertension in the general community has contributed to the reduction in strokes and coronary heart disease observed during the past 30 years. However, concerns have arisen that some patients may be receiving unnecessary antihypertensive drug therapy leading to wasted resources and the potential for adverse drug effects. Once therapy has been started, treating physicians have difficulty in selecting patients for withdrawal and have concerns regarding patient safety and their own legal liability. PROCEDURES: This study reviews and consolidates information from published studies to identify known predictors of the successful maintenance of normotension after antihypertensive drug withdrawal. The predictors were identified by determining the proportion of subjects with various baseline characteristics who remained normotensive while off medication for at least 12 months. From these data we have developed a clinical algorithm to help identify patients in whom antihypertensive drug withdrawal might be considered. This may assist primary care physicians in achieving successful withdrawal of antihypertensive therapy among selected hypertensive patients. RESULTS: The most consistent predictors identified were blood pressure (BP) (lower pretreatment, on treatment, and after withdrawal), nature of pharmacotherapy (fewer agents and lower dose), and preparedness to accept dietary intervention (weight and sodium reduction). CONCLUSIONS: On the basis of this information, a trial of withdrawal of antihypertensive medication might be recommended for patients who have mildly elevated, uncomplicated BP that is well controlled on a single agent, and who are motivated and likely to accept lifestyle changes.

Antihypertensive Agents↗
PubMed2002

An introduction to risk management.

Risk management is formally defined as the process by which an organization assesses and addresses its risks. Historically, the role of risk management has been associated with insurance-buying, occupational safety and health, and legal liability management. In recent years managers and physicians alike have begun to recognize that organizational risks are pervasive, that these risks are extraordinarily diverse and complex, and that these risks are not just confined to "insurable" or accident-related situations. They may include risks arising from actions of regulatory bodies, third party payers, hospitals, partners, and employees, in addition to the physiatrist's personal or business investment, management and clinical practice. Furthermore, changing customer and patient preferences and/or expectations make the assessment of risk an even more dynamic and continuous process. This article describes the formal risk management process and suggests ways that physiatrists can apply risk management to their business and clinical practice. In developing this description, physiatrists and their office managers will learn about the overall goals and objectives of risk management, the challenge of identifying and analyzing risks, the tools and treatment options available, and the means by which risk management efforts are effectively implemented.

Humans↗
PubMed2001

Computerised clinical pathway management systems and the implications.

This is the second paper of the two-part series. Part 1 of the series (Reconceptualising Clinical Pathway System Design) reported defects existed in the paper clinical pathways and proposed a set of design premises to guide the development of a computerised clinical pathway management system (CCPMS). This paper provides an overview of a robust CCPMS that was designed to accurately map patients' changing clinical states and support dynamic modification of the clinical pathway structure and associated interventions. This electronic system provides clinicians with real time outcome feedback on care delivered and generates alerts on out of range assessment results, deteriorating trends and potential problems such as drug interactions. It has been rated by clinicians who participated in an evaluative study as a highly useful information management and decision support tool. However, the introduction of a power tool like the clinical pathway management system has raised very important issues such as the need for work practice redesign, education of clinicians and more research to maximise the benefits of the tool and achieve better process quality improvement. It also generates serious concerns about legal liabilities and the potential threat of the cost cutting strategies taken by senior management in search of paybacks after their implementation. These issues and their implications are also explored in this paper.

Critical Pathways↗
PubMed2000

Policy for cryptography in healthcare--a view from the NHS.

Effective security arrangements, which both protect and assure those information assets of healthcare providers, doctors and patients, are fundamental requirements in a modern electronic healthcare culture. At the heart of healthcare information systems in future will be those infrastructure components and services, which underpin the principles of confidentiality, integrity and availability. Before embarking upon any major implementation of cryptographic support services, there are a number of critical policy issues, which must first be considered and addressed. To address these successfully will maximise the potential values of these services and facilities to their users on a broad front. A primary consideration for all information security projects, is the need to establish clear scope and objectives for the security services to be implemented. When considering the policy, scope and design implications of a large scale cryptography programme, a number of external issues also need to be considered not least of which are the legal liabilities, implications and obligations of the country or countries where the system(s) will operate. Where such legislation exists, regulatory arrangements may potentially influence how secure information sharing across international healthcare boundaries can be achieved.

Computer Security↗
PubMed2006

Multidisciplinary care in oncology: medicolegal implications of group decisions.

Consensus is growing that multidisciplinary meetings (MDMs) provide the best means of formulating comprehensive treatment plans for patients with cancer. Although many doctors attend MDMs and contribute to the decision-making process, only a few will become involved in a patient's care after the team meeting. Despite this, if a patient was grieved by a decision made in a MDM and wished to recover damages, all doctors present at the meeting would be personally accountable for decisions related to their area of expertise. Doctors should be made aware of the legal implications of their participation in such meetings. A greater awareness of these responsibilities and improved team dynamics should optimise outcomes for patients while limiting exposure of the participants to legal liability. Special attention should be given to providing patients with adequate information in this combined speciality setting.

Humans↗
PubMed2006

Facilitating and impeding factors for physicians' error disclosure: a structured literature review.

BACKGROUND: It is important for physicians to disclose medical errors to institutions (for patient safety), to colleagues (for professional learning), and to patients (as part of direct patient care), but no comprehensive review of factors that may facilitate or impede disclosure has been undertaken. METHODS: A MEDLINE search was conducted of English-language articles published from 1975-2004, with review of bibliographies. A total of 5,509 articles were reviewed by title, 881 articles were retrieved for full text review, and 475 articles satisfied the inclusion criteria. Article content was assessed by identifying factors that facilitate or impede disclosure and classifying each article's primary goal of disclosure. RESULTS: Thirty-five factors believed to facilitate disclosure were identified (for example, accountability, honesty, restitution), as were 41 factors believed to impede it (for example, professional repercussions, legal liability, blame). The three most common goals of disclosure were to improve patient safety, enhance learning, and inform patients. Facilitating factors were more commonly cited when the goal of disclosure was to inform patients. DISCUSSION: A wide range of factors are capable of facilitating or impeding the disclosure of medical errors. Innovations to enhance error disclosure should address both sides of the equation: impeding factors should be removed and facilitating factors should be promoted.

Communication Barriers↗
PubMed2003

Psychosocial issues and their relevance to the cosmetic surgery patient.

Psychosocial issues permeate the field of cosmetic surgery: 1. The preoperative psychological profile of cosmetic surgery patients is likely to differ from that of people who don't come for surgery. Despite several decades of research, this difference is not well understood. 2. Cosmetic surgery patients often look for more than changes in their physical appearance. If these procedures do not lead to improvements in body satisfaction, self-esteem, or quality of life, then what is their purpose? 3. Patient-surgeon rapport is not simply a nice plus if it happens. Patient satisfaction, reduced legal liability, and improved surgical outcome can all be direct reflections of the surgeon's mastery of relationship-building techniques. 4. Identifying and screening out patients who should not have cosmetic surgery can prevent both patient and surgeon frustration and more extreme adverse outcomes. 5. A wide range of studies document the use of psychological techniques to improve surgical outcome.

Body Image↗
PubMed2002

Informed consent in complementary and alternative medicine: current status and future needs.

"Informed consent" is an action. It is a process that fulfills the pretreatment ethical obligations of provider to patient. Through the process, the provider discloses meaningful and realistic facts about positive and negative expectations concerning the proposed intervention and addresses concerns that are pertinent to the patient. Disclosure is of facts that are known or realistically expected to be known by a qualified provider regardless of background or product genus. The disclosure obligation does not vary with the background of the provider or the label given to the therapy. MD, nurse, naturapath, chiropractor, and licensed and unlicensed practitioner have the responsibility to provide quality information about the therapeutic worth of the intervention based on reliable data. This obligation pertains whether the intervention is standard, experimental, investigational, natural, alternative, complementary, or unproven. Misrepresentation of material facts voids consent and triggers legal liability. Today, the oncology community meets the informed consent obligation through a stepwise process that produces standards of care and builds studies and data collection to produce reliable outcome information on patient benefit. These data enrich the ability of a patient to consider and provide informed consent to treatment. In contrast, although there are some ongoing studies of complementary and alternative (CAM) therapies, there does not appear to be a groundswell of support for these activities within the CAM community. The development of standards of care and reliable information about CAM therapies appears to be seriously lagging and a disservice to obligations toward informed participation and consent by the patients seeking CAM interventions.

Anecdotes as Topic↗
PubMed2002

Legal and ethical issues confronting oncology nursing.

OBJECTIVES: To identify and summarize the legal and ethical issues found in the multiple settings in which oncology nurses practice. DATA SOURCES: Lexis, Medline, Westlaw, federal and state laws, government documents, and nursing and medical textbooks. CONCLUSIONS: Oncology nurses face many legal and ethical dilemmas when delivering care. The best defense against litigation is to be knowledgeable about the specific issues found in each setting, the impact these issues have on practice, and requisite risk reduction practices. IMPLICATIONS FOR NURSING PRACTICE: With the advent of new technology, changing state and federal laws, and new court decisions, the ethical and legal issues nurses will encounter when taking care of cancer patients will not remain the same. Continuing education will be essential if nurses are to remain current, lower their legal liability, and deliver quality care.

Aged↗
PubMed2002

Legal issues in the early detection and monitoring of cancer.

OBJECTIVES: To identify the legal and ethical issues involved in the detection/monitoring of cancer. DATA SOURCES: Westlaw, Lexis, Medline, and legal and nursing literature. CONCLUSIONS: The introduction of genetic predisposition to cancer has increased the legal and ethical issues associated with the detection of cancer. IMPLICATIONS FOR NURSING PRACTICE: The expanding role of nurses has opened up many exciting new roles in the area of early detection of cancer including genetic counseling. Along with the new opportunities comes increased legal liability and ethical controversies that oncology nurses must be aware of.

Confidentiality↗
PubMed2002

[Risks and injuries of go-karting].

The demands on leisuretime activities are getting more exacting. So trendy sports just like inline-skating, mountain-biking, paragliding, bungee-jumping or driving go karts become increasing popular. On the other side risks and injuries of this fun sports are not enough represented. We observed in a 16 months period 5 serious accidents with go karts. The injuries included bruise of lower leg, a contusion of the stomach with a pancreatic lesion, an instable fracture of the spinal column, a difficult fracture of the knee and upper tibia and a large sized burnwound. The mean hospitalization time was 32,5 days (17-54 days) and the average age of the patients 27,7 years (9-45 years). The lack of safety devices and the subjective inexperience make go kart driving a dangerous fun. The TUV worked out guidelines for security of indoor kart centres but they don't have any legal liability in case of injury. Therefore everyone carrying out fun sports like go kart driving should be aware of the dangers and should gather information whether the accident insurance will help out in case of injury.

Adolescent↗
PubMed2004

[Forensic aspects in pregnancy].

Modern pregnancy care requires specific management, constant medical training, as well as 24 hour employment of midwives and gynaecologists. But not only medical aspects determine such pregnancy care - there are also many juridical problems. The author comments on pregnancy care contact, maternity guidelines and the guidelines of the scientific advisory council of the professional organisation of German doctors regarding prenatal diagnosis. Higher court judgements regarding medical duties when treating pregnant patients are cited. An important chapter deals with legal liability and damage amount in case of breach of duty. Finally, principles of medical information, duty of documentation and other forensic aspects of modern pregnancy care are explained.

Documentation↗
PubMed1999

Medicolegal aspects of imaging and Internet communications.

Many facial plastic surgeons have set up their own personal World Wide Web (WWW) pages with an electronic mail link to communicate with and educate prospective patients. The possible dilemma is in that these services are provided without actually meeting patients face to face. Also, despite the growing popularity of computer imaging systems, it is not clear whether the medical and legal advantages of using such a system outweigh the disadvantages. The purpose of this article is to evaluate these aspects and to provide some protective guidelines. An examination of possible causes of actions arising from computer imaging suggests that surgeons who follow a few simple guidelines, and who use computer imaging responsibly and cautiously, minimize their legal liability. Issues surrounding Internet discussion groups, posted medical advice, intellectual property, and the use of an electronic mail link are also discussed.

Humans↗
PubMed2001

Principles of biocompatibility for dental practitioners.

This article is an evidence-based tutorial on the principles of biocompatibility. Although the technical issues of biocompatibility may seem beyond the scope of most practicing dentists, knowledge of these issues is fundamentally important to ensure the health of patients, dental staff members (including laboratory personnel), and practitioners themselves. Furthermore, the legal liability of dentists is often linked to biocompatibility issues. The biocompatibility of a material is not absolute; it must be measured with regard to the way the material is used. Measuring biocompatibility is a complex process that involves in vitro and in vivo tests. These tests contribute to understanding biologic responses to a material but cannot define the material's biocompatibility with 100% certainty. Practitioners should understand enough about biocompatibility testing methods to critically judge advertising claims and ask relevant questions of manufacturers. Because there is no infallible way to assess biologic response to a material, decisions about the clinical use of a material ultimately must weigh the biologic risks of a material against its potential benefits.

Biocompatible Materials↗
PubMed2002

No-suicide contracts: an overview and recommendations.

No-suicide contracts, in their various forms, can deepen commitment to a positive action, strengthen the therapeutic alliance, facilitate communication, lower anxiety, aid assessment, and document precautions. Conversely, they can anger or inhibit the client, introduce coercion into therapy, be used disingenuously, and induce false security in the clinician. Research on no-suicide contracts (frequency surveys, assessments of behavior after contracting, and opinions of users) has limitations common to naturalistic studies, and is now ready for more rigorous methods. Mental health professions should be trained to deal with suicidal individuals, including how to use no-suicide contracts. Good contracts are specific, individualized, collaborative, positive, context-sensitive, and copied. However, they are not a thorough assessment, a guarantee against legal liability, nor a substitute for a caring, sensitive therapeutic interaction. No-suicide contracts are no substitute for sound clinical judgment.

Adolescent↗
PubMed2001

Issues in public health entomology.

Public health entomology focuses on the population biology of vector-borne infections, seeking to understand how such pathogens perpetuate over time and attempting to devise methods for reducing the burden that they impose on human health. As public health entomology passes its centennial, a series of pervasive research themes and spirited debates characterize the discipline, many reflecting a tension between field and laboratory research. In particular, institutional support for population-based research and training programs has fallen behind that for those using modern lab-based approaches. Discussion of modes of intervention against vector-borne infections (such as deployment of genetically modified vectors, the role of DDT in malaria control, host-targeted acaricides for Lyme disease risk reduction, and truck-mounted aerosol spraying against West Nile virus transmission) illustrates the discipline's need for strengthening population-based research programs. Even with the advent of molecular methods for describing population structure, the basis for anophelism without malaria (or its eastern North American counterpart, ixodism without borreliosis) remains elusive. Such methods have not yet been extensively used to examine the phylogeography and geographical origins of zoonoses such as Lyme disease. Basic ecological questions remain poorly explored: What regulates vector populations? How may mixtures of pathogens be maintained by a single vector? What factors might limit the invasion of Asian mosquitoes into North American sites? Putative effects of "global warming" remain speculative given our relative inability to answer such questions. Finally, policy and administrative issues such as the "no-nits" dictum in American schools, the Roll Back Malaria program, and legal liability for risk due to vector-borne infections serve to demonstrate further the nature of the crossroads that the discipline of public health entomology faces at the start of the 21st Century.

Animals↗
PubMed2004

Legal issues associated with the current and future practice of anti-aging medicine.

This article addresses legal issues and laws that govern physicians, medications, drugs, and the safety of patients in age management and anti-aging medical practices. Age management programs continue to increase and attract more patients despite the lack of scientific proof of their medical benefits. The use of growth hormone, other medications, and supplements is widely reported, although prohibited by the Food and Drug Administration for the treatment of anti-aging. The categories of potential legal liability presented in this article include False Expectations, Fraud, Negligence-Malpractice, Warranty Issues, Product Liability, Human Growth Hormone Usage, and Agency (employee) Issues. This article attempts to identify potential areas of liability for the age management practitioner and the patient seeking such care.

Aged↗
PubMed1982

The moral responsibility of the hospital.

The hospital has legal liability. Does it also have moral responsibility? Is it a moral agent, and if so in what sense? There are two issues involved, one conceptual and the other normative. The conceptual issue is whether a hospital can be morally responsible. If seen not only as a physical facility but as a formal organization, it can be said to act rationally, choose between alternatives, and affect human beings. It thus satisfies the criteria for moral responsibility, even though it is not a person. Though moral responsibility can be attributed intelligibly to a hospital, such responsibility can be assumed only by those within it who act for it. Such responsibility is agent responsibility and may be shared in a number of ways. Hospital responsibilities can be separated from the professional moral responsibility and the personal moral responsibility held by doctors, nurses, and others within a hospital. Assuming these three types of responsibility makes possible conflicts of responsibility for those who hold them. Normatively, the moral responsibility of the hospital is appropriately limited by its purpose and is primarily administrative. It has designatable moral responsibilities to its patients, doctors and nurses, and the public. These can be distinguished from the responsibilities of doctors and nurses to the public. The responsibility of a doctor on the hospital staff is different from the responsibility of a doctor who simply practices in the hospital; that of a staff nurse from that of a private nurse. The difference is in large part a function of the one sharing the responsibility of the hospital and the other not. An analysis of a hospital's moral responsibilities suggests structures appropriate to a hospital that wishes to meet its moral responsibilities.

Ethics↗